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Apr 22 1011:59a 763-213-0695 p.2 <br /> o,�o.,vc' <br /> Parcel number: �7�S GG'.zr1�r� �� ��� I�✓'�'S f-System stai�s: (�Complia�t ❑Noncompliant <br /> -- (as determined by this fo�m) <br /> Soil Separation Cornpliance and Other Co�npliance , <br /> Compliance Issue #3 of 4 � ' � . <br /> Date of observation: "'(��/�/C • Reason for observation: <br /> ; , <br /> This information on this form does not expire. <br /> Compliance questionslcriteria: (Required) Verification Method"'*: (Optionaf) <br /> (Check the apprcpriate box) (Check the appropriate box) <br /> For systems b�ilt prior io April 1, 1996, and nol � Conducted soil observation(s)(attach boring logs} <br /> located in Shoreland or Wellhead Protection <br /> Area or not serving a food, beverage or ❑ Two previous verifications(attach boring logs) <br /> lodging establishment: ❑ Other. <br /> Does lhe system have at least a two-ioot <br /> vertical separation distance from periodically <br /> saturatea soil or bedrock? Yes No <br /> �or non-performance systems buili April 1, <br /> 1996, or laler or for non-per,'ormance systems 5oi!observation does not expire.Previous observations <br /> located in Shoreland or Wellhead Protection �by two independent parties are sufficient, unless sile <br /> Areas or serving a food, beverage or lodging I conditions have been altered. <br /> establishrnent: <br /> Does the system have a three-foot vertical <br /> separation distance from periodicafly saturated <br /> soil or bedrock?' �Yes ❑ No <br /> �or reduced separation distance systems(i.e., * May be reduced by up to 95percenf rfalrowed in local <br /> "perorrnance" systems under old 7080,0179 or o�dinance, <br /> Type IV or V system under new 7080. 235��or � <br /> 7080.2400): I "'No standard protocol exists. This list is not exhaustive, <br /> Does the syslem meet the designed veriical in sequenfial order, nor does it indicate which <br /> corrrbrnafrons are necessary to make this <br /> separation disiance from periodically saturated determinatiqn. <br /> soil �r bedrock?" Yes ❑ No <br /> Any"no"answer indicates thai the system is failing to p�otect <br /> ground water. <br /> Certification <br /> This.`orm is io be completed and attached to the Summary Form of the Minnesota Pollution Contral Agency's(MPCA)Compliance <br /> Inspection Form for Exisiing Subsurface Sewage Treatment Systems. Observatlons, interpretaiions,and concjusions must be <br /> completed by an inspector or designer. Completed form musi be submitted to the local unil of government witt�in 15 days. <br /> Property owner nameisl: j U�� ��L�`� <br /> Property address: y � � �''�' <br /> � . <br /> Properly owner's address(if different): __ �"�►''- •��-- <br /> CountY: _.._._.�0�..,_.; - __ Phone: ��0�-O Z�. � � <br /> 1 hereby certify fhat I pe�sonalJy made the obsen�afions, inierp�etations, and conclusions reported on ihis form and that they are <br /> correct. <br /> Name: ���n._���-p � Certification number: o�i��� <br /> Business license name and num�er: 7�}—�/l/dC''�y�J" C`��5t+°G'n�. ��C� � �---- _— ar <br /> Narne of locai unii of governmer�t� ! �- <br /> Signature: Zo - Dat�l�r '/� <br /> � <br /> wq-wwists4-31 Compl iance fnspection Form for Existing SS7S <br />